Abdominal wall hernias The classical surgical definition of a hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. Risk factors for abdominal wall hernias include: obesity ascites increasing age surgical wounds Features palpable lump cough impulse pain obstruction: more common in femoral hernias strangulation: may compromise the bowel blood supply leading to infarction Types of abdominal wall hernias: Inguinal hernia Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia. Above and medial to pubic tubercle Strangulation is rare Femoral hernia Below and lateral to the pubic tubercle More common in women, particularly multiparous ones High risk of obstruction and strangulation Surgical repair is required Umbilical hernia Symmetrical bulge under the umbilicus Paraumbilical Asymmetrical bulge - half the sac is covered by skin of the abdomen directly hernia above or below the umbilicus Epigastric Lump in the midline between umbilicus and the xiphisternum hernia Most common in men aged 20-30 years Incisional hernia May occur in up to 10% of abdominal operations Spigelian hernia Also known as lateral ventral hernia Rare and seen in older patients A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally) Obturator A hernia which passes through the obturator foramen. More common in females hernia and typical presents with bowel obstruction 1 Richter hernia A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect Abdominal wall hernias in children: Congenital inguinal Indirect hernias resulting from a patent processusvaginalis hernia Occur in around 1% of term babies. More common in premature babies and boys 60% are right sided, 10% are bilaterally Should be surgically repaired soon after diagnosis as at risk of incarceration Infantile umbilical Symmetrical bulge under the umbilicus hernia More common in premature and Afro-Caribbean babies The vast majority resolve without intervention before the age of 4-5 years Complications are rare Benign prostatic hyperplasia Benign prostatic hyperplasia (BPH) is a common condition seen in older men. Risk factors age: around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms. Around 80% of 80-year-old men have evidence of BPH ethnicity: black > white > Asian BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into: voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia post-micturition: dribbling complications: urinary tract infection, retention, obstructive uropathy Management options watchful waiting medication: alpha-1 antagonists, 5 alpha-reductase inhibitors. The use of combination therapy was supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial surgery: transurethral resection of prostate (TURP) Alpha-1 antagonists e.g. tamsulosin, alfuzosin decrease smooth muscle tone (prostate and bladder) considered first-line, improve symptoms in around 70% of men adverse effects: dizziness, postural hypotension, dry mouth, depression 2 5 alpha-reductase inhibitors e.g. finasteride block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months. They may also decrease PSA concentrations by up to 50% adverse effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia Inguinal hernia Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia. Features groin lump: disappears on pressure or when the patient lies down discomfort and ache: often worse with activity, severe pain is uncommon strangulation is rare Whilst traditional textbooks describe the anatomical differences between indirect (hernia through the inguinal canal) and direct hernias (through the posterior wall of the inguinal canal) this is of no relevance to the clinical management. Management the clinical consensus is currently to treat medically fit patients even if they are asymptomatic a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients mesh repair is associated with the lowest recurrence rate The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks Complications early: bruising, wound infection late: chronic pain, recurrence Abdominal pain The table below gives characteristic exam question features for conditions causing abdominal pain. Unusual and 'medical' causes of abdominal pain should also be remembered: 3 myocardial infarction diabetic ketoacidosis pneumonia acute intermittent porphyria lead poisoning Condition Characteristic exam feature Peptic ulcer disease Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating Gastric ulcers: epigastric pain worsened by eating Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc) Appendicitis Pain initial in the central abdomen before localising to the right iliac fossa Anorexia is common Tachycardia, low-grade pyrexia, tenderness in RIF Rovsing's sign: more pain in RIF than LIF when palpating LIF Acute pancreatitis Usually due to alcohol or gallstones Severe epigastric pain Vomiting is common Examination may reveal tenderness, ileus and low-grade fever Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey- Turner's sign) is described but rare Biliary colic Pain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. Slight misnomer as the pain may persist for hours Obstructive jaundice may cause pale stools and dark urine It is sometimes taught that patients are female, forties, fat and fair although this is obviously a generalisation Acute cholecystitis History of gallstones symptoms (see above) Continuous RUQ pain Fever, raised inflammatory markers and white cells Murphy's sign positive (arrest of inspiration on palpation of the RUQ) Diverticulitis Colicky pain typically in the LLQ Fever, raised inflammatory markers and white cells Abdominal aortic Severe central abdominal pain radiating to the back aneurysm Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock) Patients may have a history of cardiovascular disease Intestinal History of malignancy/previous operations obstruction Vomiting Not opened bowels recently 'Tinkling' bowel sounds 4 Breast disorders The table below describes some of the features seen in the most common breast disorders: Fibroadenoma Common in women under the age of 30 years Often described as 'breast mice' due as they are discrete, non- tender, highly mobile lumps Fibroadenosis (fibrocystic Most common in middle-aged women disease, benign mammary 'Lumpy' breasts which may be painful. Symptoms may worsen dysplasia) prior to menstruation Breast cancer Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering Paget's disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the skin/areola Mammary duct ectasia Dilatation of the large breast ducts Most common around the menopause May present with a tender lump around the areola +/- a green nipple discharge If ruptures may cause local inflammation, sometimes referred to as 'plasma cell mastitis' Duct papilloma Local areas of epithelial proliferation in large mammary ducts Hyperplastic lesions rather than malignant or premalignant May present with blood stained discharge Fat necrosis More common in obese women with large breasts May follow trivial or unnoticed trauma Initial inflammatory response but may develop into a hard, irregular breast lump Rare and may mimic breast cancer so further investigation is always warranted Breast abscess More common in lactating women Red, hot tender swelling Lipomas and sebaceous cysts may also develop around the breast tissue. Scrotal problems Epididymal cysts Epididymal cysts are the most common cause of scrotal swellings seen in primary care. Features separate from the body of the testicle found posterior to the testicle 5 Associated conditions polycystic kidney disease cystic fibrosis von Hippel-Lindau syndrome Diagnosis may be confirmed by ultrasound. Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts. Hydrocele A hydrocele describes the accumulation of fluid within the tunica vaginalis. They be divided into communicating and non-communicating: communicating: caused by patency of the processusvaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life non-communicating: caused by excessive